This is a media release by Deighton Pierce Glynn, reshared by INQUEST
Before HM Area Coroner Laurinda Bower
Nottingham City & Nottinghamshire Coroner’s Court
15 November 2025 – 4 February 2026
Matthew was 39 years old when he took his own life in the segregation unit at Sodexo’s HMP Lowdham Grange on 25 November 2023. Matthew was the 5th man to die at the prison in 2023. The inquest has shown the brutal treatment and conditions Matthew experienced in the days and weeks before his death.
Sodexo were awarded the contract to manage the prison by the Ministry of Justice. Sodexo took control of the prison on 16 February 2023, following the first private provider to private provider transfer. Within 37 days 3 men were dead. Anthony Binfield died on 6 March 2023, David Richards on 13 March and Rolandas Karbauskas on 25 March. All died by ligature. Early learning from these men’s deaths highlighted a catalogue of systemic failings at the prison. Sodexo failed to learn lessons and to implement basic safety measures. The same problems were persisting 7 months later, and Ricky Crosher became the 4th man to die by ligature at the prison on 11 October. Juries have found serious, repeated, systemic failings contributed to the deaths of all these men.
The jury have found that multiple systemic failings also contributed to Matthew’s death, including that there was:
- A failure by Sodexo to have in place a sufficient number of staff to run a safe, secure and decent regime.
- A failure by Sodexo to assure themselves as to the capabilities of the staffing body and to remedy any deficiencies by supplying staff with training and support, especially where staff roles had been extended under the new Sodexo model.
- A failure by Sodexo to establish a robust system of management functions including consistent visible management in segregation, quality assurance processes, governance and supervision of staff.
- A sustained failure by Sodexo to adequately address the operational safety concerns raised by the Ministry of Justice between February to November 2023.
- A failure by Sodexo to adequately embed learning from previous deaths in custody, meaning past failings were repeated in Matthew’s care with regards to the appreciation and management of his risk.
- A failure by Nottinghamshire NHS Trust to have in place a sufficient number of mental healthcare staff to provide Matthew with appropriate person-centred care.
- A failure by Nottinghamshire NHS Trust to have in place a robust system of healthcare management functions including quality assurance processes and clinical supervision of staff.
Matthew’s sister, Jasmine, told the inquest that Matthew was “kind, protective, adventurous, impulsive and full of life”. She explained that Matthew was “a hard worker in the building trade, someone who had worked since leaving school, always willing to get up early and get things done”. He loved fitness and to experience life fully including skydiving and he travelled extensively. Jasmine explained “travel gave him peace and helped him with his mental state”. Jasmine also told the jury Matthew “did not always have an easy childhood spending time in foster care and like the prison system later, he was not given the support he needed”.
Matthew’s time at Lowdham Grange
At the time of Matthew’s death, he was recognised as at risk of self-harm and suicide and being managed under prison ACCT procedures (national prison policy to manage and care plan for those at risk of self-harm and suicide). A month after arriving at the prison, in July 2023, Matthew made 3 serious attempts on his life by ligature. An ACCT was opened, and he remained on the ACCT for almost 5 months before he died.
On 3 October 2023, Matthew was transferred to the prison’s Segregation Unit where it was documented in his ACCT record that staff believed he initiated violence against his person as a form of self-harm.
It was Matthew’s 54th day in the Segregation Unit when he died, on Saturday 25 November 2023. For vulnerable people, like Matthew, segregation can only be authorised in exceptional circumstances. The inquest has found that the strict legal processes designed to ensure segregation is only imposed as an exceptional measure, were not followed. Matthew was unlawfully held in the Segregation Unit for at least the last 9 days of his life.
Matthew was also not receiving the support he should have been given through his ACCT. Matthew should have had 3 meaningful conversations with prison staff a day and observed at least 3 times per hour. His care also should have been multidisciplinary. On the day of his death, Matthew had not even been observed for nearly 2 hours, between 14:32 and his discovery at 16:22.
Matthew was not receiving support from the mental health team at the time of his death. He had been discharged from the mental health team and psychiatrist’s caseloads. There were many failings to provide him the individualised mental health support he clearly required.
The inquest heard harrowing evidence about the extreme isolation in the Segregation Unit and the increasingly desperate behaviour Matthew was exhibiting over the days before his death. Duty Managers should have seen Matthew on daily rounds and made defensible decisions about his continued segregation, this did not happen or decision making was not properly recorded on multiple days, such that the rationale for keeping Matthew in harsh segregation conditions is unclear.
In the weeks before Matthew’s death, a physical health nurse sent whistleblowing emails to senior prison managers about her safeguarding concerns for several men held in the Segregation Unit and questioned their fitness to be held in segregation. The nurse’s emails noted a specific concern about a deterioration in Matthew’s mental health in the Segregation Unit. There is no evidence of any adequate response to these concerns being raised.
People should never be subject to solitary confinement. However, the evidence shows there were less than 3 minutes when Matthew’s door was open in the 3 days before his death. Matthew was being held without meaningful human interaction. He had no way to contact his family, as he had no phone in his cell. He had no radio, no tv and no reading or writing distraction materials in his cell. When Matthew was last seen by prison staff, hours before his death, he was sat on his bed staring at his cell wall.
The jury found a series of failures and missed opportunities by prison and healthcare staff more than minimally contributed to Matthew’s death, including:
- Mental Health's failure to provide adequate personalised care and support for Matthew, complete adequate segregation checks, and refit Matthew with the algorithm when concerned he is acutely unwell.
- Prison staff failure to complete sufficient quantity and quality of ACCT checks and conversations, segregation review boards, and daily defensible decisions.
- Lack of management oversight for healthcare and the prison to ensure quality assurance of standards of care.
- Insufficient staff across prison and healthcare prevented vital support systems from being implemented, including keywork, and ongoing concerns being adequately acted upon.
- Prison staff failure to move Matthew from 16 November when exceptional circumstances for his continued segregation were no longer met and therefore unlawful.
Shocking new evidence at the inquest
During the course of the inquest, CCTV footage from 22-24 November was finally disclosed. This is footage that has been available to Sodexo for over 2 years. Careful analysis of that footage by Matthew’s Family’s legal team, while the court hearings were underway, showed that:
- On 22 November, Matthew made an attempt to hit a prison officer. He was restrained by 3 officers and use of force procedures were used to relocate Matthew back to his cell. The officer’s body worn footage of the use of force shows the uninhabitable state of Matthew’s cell. Matthew’s foam mattress was torn into chunks strewn across his cell, leaving Matthew in a cell with a bare metal bed frame. The CCTV proves that no replacement mattress was taken to Matthew’s cell. Despite prison staff being fully aware of the state of Matthew’s cell, he was left in those inhumane conditions for a further 26 hours. Furthermore, the jury found it was likely that Matthew had been in that inhumane cell since 21 November.
- On 23 November, Matthew was searched by 3 officers before finally being moved cells. During the search, a strip of material was found in Matthew’s waistband. Prison witnesses admit this discovery should have led to an urgent multidisciplinary review of Matthew’s circumstances, recognition of increased risk and care plans being implemented. Instead, the material was simply handed back to Matthew, and the incident is not recorded at all.
- Shockingly, the CCTV footage also evidences endemic falsification of Matthew’s ACCT record by multiple prison officers, over the days for which footage is available. The majority of checks that were recorded as taking place, were shown to not occur as recorded. More hours than not there were false records.
Inadequate investigations and learning after Matthew’s death
Following Matthew’s death, disciplinary investigations were undertaken against officers working on the Segregation Unit on the day Matthew died. 1 officer resigned before the investigation concluded and 2 were dismissed for gross misconduct. Sodexo were unable to explain why the multiple managers involved in the unlawful decision making about Matthew being held in segregation and/or the failure in his ACCT management, were not investigated or subject to disciplinary proceedings.
Despite a well-documented history of serious safeguarding concerns being raised about the Segregation Unit and prison staff behaviour in 2023, there was no evidence of Sodexo implementing robust mechanisms to reduce the risk of individual failings, such as those of the Segregation Unit officers. The Prison’s Deputy Director gave evidence that her decisions in unrelated disciplinary processes against 2 members of operational staff were overruled by the Sodexo Prison Director in 2023. The Deputy Director noted her concerns about the impression given of Sodexo's tolerant attitude towards poor staff behaviour and the likely impact that would have on staff conduct in future. The Assistant Director Head of Safety said that he understood that there was little 'appetite' to bring performance and/or disciplinary action against staff, including middle managers, during the time Sodexo ran the prison.
Jasmine Osborne, Matthew’s sister, reflected: “Matthew was left for months without appropriate mental health treatment and without staff having a proper understanding of his mental health needs. The inquest has heard evidence that ACCT observations were recorded when they had not been carried out, meaning safeguarding measures existed on paper but not in practice. Not just for the prison but the healthcare too, both carrying out tick box exercises.
Matthew told staff that he was unwell and deteriorating, and he showed clear signs of acute mental illness. Professionals trained to recognise these warning signs failed to respond appropriately, failed to document crucial information, and ultimately withdrew support when it was most needed.
Every organisation and individual involved had a role to play in the failures exposed by this inquest. Mental health and suicide risk should never be ignored, even when someone is serving a prison sentence. Vulnerable people with complex needs should be protected and not abandoned. Matthew deserved care and the right to life.
As a family, we are broken by what has happened. No family should have to endure this. We hope the findings of this inquest lead to real accountability and meaningful change within the system and no other family is left to suffer in this way.”
Amalia King of Deighton Pierce Glynn, representing Matthew’s Family, comments: “Matthew's family have bravely fought for truth and accountability in the hope that lessons are learnt to prevent more deaths in prisons. There's been multiple investigations into Matthew’s death, including by Sodexo, Nottinghamshire Police, the Ministry of Justice and the Prisons and Probation Ombudsman, yet it's taken over 2 years for the extent of the true horror of Matthew's treatment to be revealed at his inquest.
Sodexo knew the prison was unsafe for everyone living and working there. Throughout 2023, the Prisons Inspectorate, Ministry of Justice, Independent Monitoring Board, Healthcare Whistleblowers and the Prison Staff Union were all flagging serious safety concerns to Sodexo senior management. Yet 4 men died at the prison in the months before Matthew. And still nothing effective was done to stop the same failings repeating. There was an utterly shocking absence of working safety systems at the prison.
Part of Matthew’s legacy is to have brought to light the endemic falsification of records by prison staff. This is a known issue in prisons across the country and the dangerousness of such cultures developing, and going unchecked, is now plain to see.”
Selen Cavcav, Senior Caseworker at INQUEST, says: "Lowdham Grange’s continued reluctance to learn from previous deaths is nothing short of criminal. Matthew's family know that only too well.
Matthew’s name joins a long list of people who have died following similar failures at the prison. It is indefensible that the prison has been allowed to continue to operate for so long with no accountability.
It is clear that Sodexo, a private company contracted by the Ministry of Justice to run Lowdham Grange, are putting profit over people’s lives. They must be criminally investigated for corporate manslaughter alongside the Ministry of Justice. These deaths must stop.”
ENDS
NOTES
Matthew’s family are represented by INQUEST Lawyers Group members Amalia King and Rachel Tribble of Deighton Pierce Glynn, and Taimour Lay of Garden Court Chambers. The family are supported by INQUEST caseworker Selen Cavcav.
Other Interested persons represented are Sodexo, Ministry of Justice, Nottinghamshire NHS Trust and various individuals.
HMIP Expectations state people should 'never be subject to a regime which amounts to solitary confinement'. The legal definition of Solitary confinement is ‘when detainees are confined alone for 22 hours or more a day without meaningful human contact’ (United Nations Standard Minimum Rules for the treatment of prisoners. Rule 44).
PSO 1700 National Policy on Segregation sets out the evidence of the harm solitary confinement can cause.
If you are feeling low, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Matthew Osborne
CONTENT WARNING: Please read with care as this page may involve information on death, suicide, mental illness, disability, state neglect, and police and prison violence that some people may find upsetting. If you need support, please visit our support page.
This is a media release by Deighton Pierce Glynn, reshared by INQUEST
Before HM Area Coroner Laurinda Bower
Nottingham City & Nottinghamshire Coroner’s Court
15 November 2025 – 4 February 2026
Matthew was 39 years old when he took his own life in the segregation unit at Sodexo’s HMP Lowdham Grange on 25 November 2023. Matthew was the 5th man to die at the prison in 2023. The inquest has shown the brutal treatment and conditions Matthew experienced in the days and weeks before his death.
Sodexo were awarded the contract to manage the prison by the Ministry of Justice. Sodexo took control of the prison on 16 February 2023, following the first private provider to private provider transfer. Within 37 days 3 men were dead. Anthony Binfield died on 6 March 2023, David Richards on 13 March and Rolandas Karbauskas on 25 March. All died by ligature. Early learning from these men’s deaths highlighted a catalogue of systemic failings at the prison. Sodexo failed to learn lessons and to implement basic safety measures. The same problems were persisting 7 months later, and Ricky Crosher became the 4th man to die by ligature at the prison on 11 October. Juries have found serious, repeated, systemic failings contributed to the deaths of all these men.
The jury have found that multiple systemic failings also contributed to Matthew’s death, including that there was:
Matthew’s sister, Jasmine, told the inquest that Matthew was “kind, protective, adventurous, impulsive and full of life”. She explained that Matthew was “a hard worker in the building trade, someone who had worked since leaving school, always willing to get up early and get things done”. He loved fitness and to experience life fully including skydiving and he travelled extensively. Jasmine explained “travel gave him peace and helped him with his mental state”. Jasmine also told the jury Matthew “did not always have an easy childhood spending time in foster care and like the prison system later, he was not given the support he needed”.
Matthew’s time at Lowdham Grange
At the time of Matthew’s death, he was recognised as at risk of self-harm and suicide and being managed under prison ACCT procedures (national prison policy to manage and care plan for those at risk of self-harm and suicide). A month after arriving at the prison, in July 2023, Matthew made 3 serious attempts on his life by ligature. An ACCT was opened, and he remained on the ACCT for almost 5 months before he died.
On 3 October 2023, Matthew was transferred to the prison’s Segregation Unit where it was documented in his ACCT record that staff believed he initiated violence against his person as a form of self-harm.
It was Matthew’s 54th day in the Segregation Unit when he died, on Saturday 25 November 2023. For vulnerable people, like Matthew, segregation can only be authorised in exceptional circumstances. The inquest has found that the strict legal processes designed to ensure segregation is only imposed as an exceptional measure, were not followed. Matthew was unlawfully held in the Segregation Unit for at least the last 9 days of his life.
Matthew was also not receiving the support he should have been given through his ACCT. Matthew should have had 3 meaningful conversations with prison staff a day and observed at least 3 times per hour. His care also should have been multidisciplinary. On the day of his death, Matthew had not even been observed for nearly 2 hours, between 14:32 and his discovery at 16:22.
Matthew was not receiving support from the mental health team at the time of his death. He had been discharged from the mental health team and psychiatrist’s caseloads. There were many failings to provide him the individualised mental health support he clearly required.
The inquest heard harrowing evidence about the extreme isolation in the Segregation Unit and the increasingly desperate behaviour Matthew was exhibiting over the days before his death. Duty Managers should have seen Matthew on daily rounds and made defensible decisions about his continued segregation, this did not happen or decision making was not properly recorded on multiple days, such that the rationale for keeping Matthew in harsh segregation conditions is unclear.
In the weeks before Matthew’s death, a physical health nurse sent whistleblowing emails to senior prison managers about her safeguarding concerns for several men held in the Segregation Unit and questioned their fitness to be held in segregation. The nurse’s emails noted a specific concern about a deterioration in Matthew’s mental health in the Segregation Unit. There is no evidence of any adequate response to these concerns being raised.
People should never be subject to solitary confinement. However, the evidence shows there were less than 3 minutes when Matthew’s door was open in the 3 days before his death. Matthew was being held without meaningful human interaction. He had no way to contact his family, as he had no phone in his cell. He had no radio, no tv and no reading or writing distraction materials in his cell. When Matthew was last seen by prison staff, hours before his death, he was sat on his bed staring at his cell wall.
The jury found a series of failures and missed opportunities by prison and healthcare staff more than minimally contributed to Matthew’s death, including:
Shocking new evidence at the inquest
During the course of the inquest, CCTV footage from 22-24 November was finally disclosed. This is footage that has been available to Sodexo for over 2 years. Careful analysis of that footage by Matthew’s Family’s legal team, while the court hearings were underway, showed that:
Inadequate investigations and learning after Matthew’s death
Following Matthew’s death, disciplinary investigations were undertaken against officers working on the Segregation Unit on the day Matthew died. 1 officer resigned before the investigation concluded and 2 were dismissed for gross misconduct. Sodexo were unable to explain why the multiple managers involved in the unlawful decision making about Matthew being held in segregation and/or the failure in his ACCT management, were not investigated or subject to disciplinary proceedings.
Despite a well-documented history of serious safeguarding concerns being raised about the Segregation Unit and prison staff behaviour in 2023, there was no evidence of Sodexo implementing robust mechanisms to reduce the risk of individual failings, such as those of the Segregation Unit officers. The Prison’s Deputy Director gave evidence that her decisions in unrelated disciplinary processes against 2 members of operational staff were overruled by the Sodexo Prison Director in 2023. The Deputy Director noted her concerns about the impression given of Sodexo's tolerant attitude towards poor staff behaviour and the likely impact that would have on staff conduct in future. The Assistant Director Head of Safety said that he understood that there was little 'appetite' to bring performance and/or disciplinary action against staff, including middle managers, during the time Sodexo ran the prison.
Jasmine Osborne, Matthew’s sister, reflected: “Matthew was left for months without appropriate mental health treatment and without staff having a proper understanding of his mental health needs. The inquest has heard evidence that ACCT observations were recorded when they had not been carried out, meaning safeguarding measures existed on paper but not in practice. Not just for the prison but the healthcare too, both carrying out tick box exercises.
Matthew told staff that he was unwell and deteriorating, and he showed clear signs of acute mental illness. Professionals trained to recognise these warning signs failed to respond appropriately, failed to document crucial information, and ultimately withdrew support when it was most needed.
Every organisation and individual involved had a role to play in the failures exposed by this inquest. Mental health and suicide risk should never be ignored, even when someone is serving a prison sentence. Vulnerable people with complex needs should be protected and not abandoned. Matthew deserved care and the right to life.
As a family, we are broken by what has happened. No family should have to endure this. We hope the findings of this inquest lead to real accountability and meaningful change within the system and no other family is left to suffer in this way.”
Amalia King of Deighton Pierce Glynn, representing Matthew’s Family, comments: “Matthew's family have bravely fought for truth and accountability in the hope that lessons are learnt to prevent more deaths in prisons. There's been multiple investigations into Matthew’s death, including by Sodexo, Nottinghamshire Police, the Ministry of Justice and the Prisons and Probation Ombudsman, yet it's taken over 2 years for the extent of the true horror of Matthew's treatment to be revealed at his inquest.
Sodexo knew the prison was unsafe for everyone living and working there. Throughout 2023, the Prisons Inspectorate, Ministry of Justice, Independent Monitoring Board, Healthcare Whistleblowers and the Prison Staff Union were all flagging serious safety concerns to Sodexo senior management. Yet 4 men died at the prison in the months before Matthew. And still nothing effective was done to stop the same failings repeating. There was an utterly shocking absence of working safety systems at the prison.
Part of Matthew’s legacy is to have brought to light the endemic falsification of records by prison staff. This is a known issue in prisons across the country and the dangerousness of such cultures developing, and going unchecked, is now plain to see.”
Selen Cavcav, Senior Caseworker at INQUEST, says: "Lowdham Grange’s continued reluctance to learn from previous deaths is nothing short of criminal. Matthew's family know that only too well.
Matthew’s name joins a long list of people who have died following similar failures at the prison. It is indefensible that the prison has been allowed to continue to operate for so long with no accountability.
It is clear that Sodexo, a private company contracted by the Ministry of Justice to run Lowdham Grange, are putting profit over people’s lives. They must be criminally investigated for corporate manslaughter alongside the Ministry of Justice. These deaths must stop.”
ENDS
NOTES
Matthew’s family are represented by INQUEST Lawyers Group members Amalia King and Rachel Tribble of Deighton Pierce Glynn, and Taimour Lay of Garden Court Chambers. The family are supported by INQUEST caseworker Selen Cavcav.
Other Interested persons represented are Sodexo, Ministry of Justice, Nottinghamshire NHS Trust and various individuals.
HMIP Expectations state people should 'never be subject to a regime which amounts to solitary confinement'. The legal definition of Solitary confinement is ‘when detainees are confined alone for 22 hours or more a day without meaningful human contact’ (United Nations Standard Minimum Rules for the treatment of prisoners. Rule 44).
PSO 1700 National Policy on Segregation sets out the evidence of the harm solitary confinement can cause.
If you are feeling low, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
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